Pulmonary Balloon Valvuloplasty in a Fetus with Critical Pulmonary Stenosis/Atresia with Intact Ventricular Septum and Heart Failure

Abstract

Outcome of fetuses with critical pulmonary stenosis (critical PS) or atresia of the pulmonary valve (PA) with intact ventricular septum (IVS) is closely related with right ventricle hypoplasia and its consequent hemodynamics. Fetal echocardiography not only allows early detection of this condition but also monitors its normally unfavorable evolution. These cases may benefit from intrauterine intervention relieving outflow tract obstruction in order to achieve a biventricular circulation. Successful valvuloplasty of the pulmonary valve was performed in a fetus with critical PS-IVS and heart failure at 25 weeks. After the procedure there was a significant improvement in fetal hemodynamics. Follow-up scans at 34 weeks detected a significant restenosis with signs of circulatory failure leading to premature delivery of the baby. An immediate postnatal valvuloplasty successfully completed the ultimate objective of biventricular repair. Fetal pulmonary valvuloplasty is feasible and may change the natural history of the disease in fetuses with critical PS-IVS.

Immediate effects and outcome of in‐utero pulmonary valvuloplasty in fetuses with pulmonary atresia with intact ventricular septum or critical pulmonary stenosis

“…Therefore, prenatal treatment could be a unique opportunity to take advantage of a better ventricular growth than that achievable postnatally. A few case reports and small case series have shown that fetal pulmonary valvuloplasty is technically feasible and associated with continued growth of RV structures8, 9, 10, 11, 12, 13. The International Fetal Cardiac Intervention Registry reported 16 fetal pulmonary valvuloplasties, of which 11 procedures were successful and resulted in seven liveborn patients, five of which were discharged with a biventricular circulation.…”

Accuracy of the Fetal Echocardiography in the High Risk Pregnancies

“…48 It was available for fetal arrhythmias, fetal heart failure, and in some cases for very few structural CHD. 15,39 The majority of neonates who have CHD will not require delivery room resuscitation in excess of routine care. 22 However, resuscitation could be required in a small number of prenatally diagnosed CHD including transposition of the great arteries with intact ventricular and restrictive atrial septum, hypoplastic left heart syndrome with intact atrial septum, obstructed total anomalous pulmonary venous return, and complete congenital heart bloc.…”

“…52 The survival after fetal aortic and pulmonary balloon valvuloplasty has been reported, and seemed very encouraging approach to the treatment of the fetal CHD. 15,53 The world discouraging experience of percutaneous ultrasound-guided balloon valvuloplasty in human fetuses with severe aortic valve obstruction was reported in 12 fetuses between 27th and 33rd weeks of gestation. 54 The range between initial presentation and intervention was 3 days to 9 weeks.…”

“…Prenatal interventions, very rarely performed on fetal heart, are becoming more available with development of new nonsurgical methods of the cardiac defect repair. 15 The question is where is development of fetal cardiology headed? At the beginning of 1990s, the first trimester transabdominal or transvaginal route of the assessment of fetal heart was developed in order to define fetal well-being and possible aneuploidy.…”

“…In those who will survive, prenatal interventions will be possible in some cases while in the others, the prognosis will be improved by the early lifesaving postnatal intervention in the cardiac tertiary centers. 15,22 The aim of the chapter is to give a brief overview on development of promising field of fetal echocardiography.…”